I think it is interesting that most of us experienced our own classical analysis and may have performed to varying degrees classical analysis where the patient lies on the couch and there is no eye contact with the therapist ! For many this was or may still be the gold standard.
Even when there is face to face therapy, to many the proper approach is for the therapist not to reveal emotions through facial expression. To do so could facilitate the development of a false transference etc etc. So now when we are forced to do remote therapy, I very much doubt that most therapists set up their screens so they are at least six feet away from their screen ( to reproduce the usual therapy setting ) or perhaps shut off their camera to do analysis in classical manner without patient seeing your face during the session. I believe that our profession has learned that we can come to understand transference in most settings, take into account and explore where our facial expression, objects in our office and information that the patient has obtained from the Internet will influence initial transference and use our techniques to interpret the patient perceptions and use analytic techniques to facilitate the therapy and help the patient.
(Dr. Blumenfield is the Sidney E. Frank Distinguished Professor of Psychiatry and Behavioral Sciences at New York Medical College and currently in private practice in Los Angeles. He is the author of a new book “ShrinkTalk” scheduled to be released in December)
It has been about 4 months since I first wrote about “Fatal Denial” and how this unconscious psychological defense mechanism is leading to thousands of preventable deaths during the Covid-19 pandemic. Denial is a well known unconscious psychological defense that we use in many situations on a regular basis. It is bolstered by another psychological mechanism of rationalizations such as a person accepting the idea that the need to wear masks is overblown, is a political issue or isn’t necessary if you are relatively young and healthy, etc. etc. The scientific facts and the reality are quite clear, in that the failure to wear masks and social distance is causing the continued increase in the number of Covid-19 cases and thousands of subsequent related deaths!!
The periodic and increased statements by scientists and health experts about the necessity to take these precautions apparently has not made any difference in this tragic situation.
I know that the people who are participating without masks and social distancing in public demonstrations and social gatherings do not want to get sick and die or cause loved ones to do the same. Nevertheless, the number of cases and fatalities continues to increase.
I have suggested that there is an approach to counter this trend which will utilize our understanding of the unconscious psychological mechanisms at play here. That would be to identify the “objects” (people) with whom the Fatal Deniers value and are their so-called heroes. This may be actors and actresses, sports figures, musicians and even in some cases politicians and other leaders. These people can be identified by running some “Focus Groups” (techniques well known to the advertising industry) with the “non maskers” who are utilizing “fatal denial”. These “heroes”( well known public figures) would then be approached and asked to participate in a massive public service outreach program that would include television, radio, Internet, billboards etc. in which they would plead with the public to save lives and wear masks, social distance etc. Also included in this public service outreach program would be segments with people who have lost loved because of COvid 19 perhaps some people who now realize how they have caused illness and death to loved ones by not taking the recommended precautions.
I have spoken to many colleagues in the mental health professions who agree with me in this analysis and suggested solution. I tried to bring these ideas to the attention of people who might be able to utilize them but so far have not made any progress. Such a program will require some financial support and hopefully cooperation of the media but surely it is worth any price.
The deadly Coronavirus epidemic continues to spread in my state of California and throughout the country. Medical experts have clearly identified the reason that the epidemic is getting out of control is that a significant number of people are not listening to the medical experts and are not using facial masks, keeping social distancing nor are they following other precautions concerning opening businesses, restaurants, beaches, sporting and political events etc. Of course, these people do not want to get sick or spread this illness to their loved ones. Such individuals are using a very common unconscious psychological defense mechanism of “denial” to keep out of their consciousness that their behavior could be fatal to themselves and their loved ones. They support this denial with another well-known psychological defense mechanism known as “rationalizations”. Examples are, “I am healthy and won’t get sick”, “These precautions by the experts are political in nature”, “You are only young once” and many other rationalizations. Because these are psychological defense mechanisms and they won’t protect anyone from this fatal virus, I have coined a new term for this denial and am calling it “FATAL DENIAL.”
In order to overcome this “fatal denial” we must communicate the message to the deniers as coming from people with whom they have a strong positive identification. There are well known scientific approaches to determine who such people would be. This is the technique of running focus groups with a wide cross section of deniers. (The advertising industry is quite skilled at utilizing this method). During such meetings it would not necessarily be important to determine the rationalization that are used but rather the scientific inquiry would be to identify who are their role models and heroes among movie, tv, music, sports and even political stars. Once these names were identified, they would be approached and be invited to participate in a massive public service announcement campaign which would speak to the Fatal Deniers. There should be TV and radio ads as well as billboards and posters as well as a concerted campaign on social media which could be made available throughout the country. In addition to the “heroes” being the face and voice of these announcements, there also should be series of such announcements done by young and older regular people who have lost loved ones to the virus.
While I would hope that celebrities might donate their time and perhaps networks would also donate free time for these pieces, there still would be costs in making them and distributing them. I would hope that Governor or California and the state legislature as well as their counterparts in other states would be interested in supporting such a program. I know TV producers who would be skilled and capable of carrying out such a program and I would be willing to help in any way that I can. Perhaps such people as Bill Gates, Jeff Bezos and others might get behind such a life saving program and provide the financial support needed.
“Fatal Denial” and How to Deal With It During the COVID-19 Epidemic
Psychiatrists and other mental health professionals deal with the defense mechanism of denial all the time. We know this to be a very basic defense mechanism which protects the individual from anxiety as well as from other painful emotions including depression. In the course of doing psychotherapy we chip away at this defense mechanism as we help the patient strengthen other methods of coping and dealing with the issues in their life. At various times all people will use a this mechanism as we usually don’t think about our mortality most of the time.
Currently during the COVID-19 pandemic we are seeing situations where many people are apparently using this defense mechanism as they choose not to wear masks, abide by social distancing and practice other behaviors which clearly endangers their lives as well as those of loved ones and other people. Watching the TV news, it is clear that this is quite common and wide spread. I am sure that these individuals do not believe they are truly endangering themselves or other people. They will use various rationalizations and will not or cannot acknowledge the life-threatening nature of their behavior. I believe that we should label this for what it is: “Fatal Denial.” Since the overwhelming majority of people who are using Fatal Denial are not in therapy nor are they motivated to be in therapy, we need to find a way to address this very serious problem.
The answer to this dilemma problem is to first personally and publicly identify the very dangerous mechanism that is widely being used. Mental health professionals need to take an active role explaining to the public how many people are denying a life-threatening situation by using Fatal Denial. Perhaps this can be done in conjunction with our medical colleagues who as a group have a generally trusted relationship with the public. I would also like to see a nationwide campaign of public service announcements where doctors (perhaps psychiatric and non- psychiatric physicians)as well as other mental health professionals and nurses appear on television expressing concern about the wide spread fatal denial that is leading to people not taking the proper protections and thereby endangering their lives and the lives of others including their loved ones.
In addition, trusted, popular public figures (whether they be entertainers, sports figures or even politicians) should appear in a wide spread series of public service announcements on TV, billboards and posters strategically located such as at the front door of a supermarkets or other stores or restaurants urging those entering to wear a mask and socially distance themselves. The reality is that many people would be more influenced by such a poster than by the entreaty of the young person at the door of a store or a waiter or a lifeguard at a beach or even by a police officer, asking them to do the right thing.
As psychiatrists and physicians, we have to call Fatal Denial for what it is and what it means. We have to mobilize our profession organizations as well as the media to try to break through this deadly defense mechanism of Fatal Denial.
The Coronavirus Epidemic: Transference and Countertransference Considerations With Remote Therapy
Michael Blumenfield, M.D.
The Coronavirus epidemic has forced psychotherapists to see patients remotely as we are forced to follow social distancing and in many cases remain quarantined. I and others have made the case that remote sessions via Zoom, Skype, FaceTime, Doxy, and other systems are not only a safer method to follow during this time of the dangerous epidemic, but under certain circumstances may be more effective than the patient and the therapist sitting across from each other wearing protective masks. Remote therapy also eliminates travel time for the patient, which often is not only a safety factor during these times, but can be quite valuable as well as convenient for the patient. I have advocated that as long as there is any health consideration, this method should be continued and have also suggested that when the health crisis has completely passed, therapists and patients may favor continuing the utilization of remote sessions.
However, as we consider making remote sessions the norm, we have to examine how changes in the method of therapy will impact our therapeutic techniques. Particularly for those of us who are psychoanalysts or psychodynamic therapists, we will need to consider how utilizing remote sessions will impact transference and countertransference. As we know, “transference” is the phenomena where the patient experiences feelings about the therapist, which originate in the patient’s childhood usually from feelings that one had for primary relationship in childhood most often from emotions related to his or her parents. Often such feelings are initially identified by feelings that the patient had towards other people in the patient’s life, but frequently get more clearly expressed in the therapeutic relationship. The transference relationship is usually facilitated by the therapist being a more or less “gray screen” meaning that the patient usually knows very little about the therapist’s personal life or actual personality. There are exceptions in training programs where the therapist may be a teacher or may have a strong presence on social media.
Now with remote therapy, we have to take into account how the characteristics of remote therapy will influence the development of the transference, the distortion of it or the facilitation of it. If the therapist chooses to hold the remote video session in a setting which reveals their personal life (i.e., showing personal photos in the background), that certainly could distort or at least influence the transference. Obviously, this would be more likely to happen if children or other family members or even pets entered into the background of the setting. The fact that many remote setups actually present much more of a close-up of each participant’s face could influence the emotional experience of the participants. Also, the clothes that the participants are wearing, personal grooming or lack of it, will all influence the emotional experience of the participants. Obviously, all the factors which delay or distort transference will also impact countertransference. In situations where psychoanalytic therapy traditionally has the patient lying on a couch so they will not be influenced by the therapist looking at them, it would seem that a procedure would be developed where both participants after greeting each other would turn off their video setting.
I believe the transference and countertransference will definitely be influenced by remote sessions. I am confident that all aspects of transference and countertransference will ultimately take place but they no doubt will be influenced by the nature and characteristics of remote therapy. It will be incumbent that we use thoughtful observations how these may be barriers or distortions in transference and countertransference with this new method.
There is another aspect of how we use our new therapeutic experience to give us insight into the struggle of our patients. During the current and apparently prolonged health crisis, social contact especially between single people has become limited to remote visits and this fact of life in many cases is limiting and distorting the emotional experience of these relationships and becomes part of the struggle of the patient. It appears to me that the patients are uncertain how to evaluate their emotional attachments when the contacts are mostly or entirely via remote communication. By examining the nature of transference in remote therapy, we will provide a method to give the patient insight into this new struggle.
I am sure there will be many papers and presentations which will be examining these issues. At this time, I would welcome and invite any comments which you can write below.